Transcript Diapositive 1

VALUE OF MRI IN CHARACTERIZATION OF
BORDERLINE OVARIAN TUMOR
H. MHALLA(1) , S. MELLITI(1), S.GHARBI DHAOUADI (1), C. MBARK(2),
H.OUESLATI (2), S.MEZGHANI(1)
(1) Radiology department, Ben Arous Hospital, Ben Arous, Tunisia
(2) Gynecological department, Ben Arous Hospital, Ben Arous, Tunisia
INTRODUCTION
Borderline ovarian tumours (BTs) are low grade malignant neoplasms and
have have a rather good prognosis. Bts account for 10 to 15% of the ovarian
tumours (1,2). Serous and mucinous are the common subtypes (3). BTs are
staged according to the same principles as malignant tumours. Inaccurate
preoperative diagnosis of a BT could result in patiens being undertreated for
an ovarian neoplasm. Correct preoperative diagnosis may allow the option of
fertility preserving ovarian surgery in selected cases.
OBJECTIVES
The aim of this study is to describe the range of magnetic resonance imaging
(MRI) appearances of Borderline ovarian tumor (BT) and to assess the
importance of preoperative diagnosis of BT for management strategies.
MATERIALS AND METHODS
5 women were referred to our department. All underwent ultrasonography
(US) and MRI. For each tumor, site, size, ultrasound features and MRI
characteristics were recorded. Laparoscopic was performed for all of the
patients. Anathomopathologic exam confirmed the diagnosis.
RESULTS
Clinical parameters
Cas
e
Gravidity/
Parity
N°1
G6P6
42
Pelvic pain
Painful pelvic mass (20
cm)
CA 125 : 9 UI /ml
(NV : 0-35UI/ml)
N°2
G0P0
31
Chronic pelvic
pain (5 months)
__
_
N°3
G7P6
51
Pelvic pain and
pelvic mass
(1month)
Abdominal and pelvic
mass (40cm)
_
N°4
G3P3
42
Pelvic pain and
pelvic mass
(4months)
Abdominal and pelvic
mass (30 cm)
CA 125 : 34 UI/ml
(NV : 0-35UI/ml)
33
Pelvic pain
_
_
N°5
G0P0
Age
Complains
Exam
CA125 levels
RESULTS
Ultrasonography morphologic analysis
Case
Size
description
N°1
17
cm
N°2
7 cm Cystic mass with solid component, thick
septations, intracystic and exophytic papillary
projections
N°3
>30
cm
N°4
N°5
Doppler
Cystic mass with thin septations and intracystic papillary projections
Controlateral
ovarian
Ascites
Normal
+/-
+
Not seen
+
Cystic mass with solid component, thin
septations without papillary projections
+
Not seen
-
>20
cm
Cystic mass with solid component, thin
septations and intracystic papillary projections
+
Normal
+/-
6
cm
Cystic mass with thin septations with intracytic
and exophytic papillary projections
+
Normal
+
Abdominal and pelvic cystic mass with thin septations and papillary projections
Ultrasonography morphologic analysis of adnexal masses was accurate for
identifying ovarian site, suspecting epithelial tumor and to confirm its neoplastic
nature.
MRI PROTOCOL
•Use of a pelvic multicoil
•Sagittal inversion recovery localizer sequence
•
• axial
and FSE T2 weighted sequence
•axial T1 weighted sequence and an optional axial Tl-weighted sequence
with fat saturation if a high signal in T1 weighted images is identified ( for
differentiating lipid-containing masses from hemorrhagic adnexal lesions)
•Typical parameters for the FSE T2-weighted sequence :
–TR, 5,000 to 7,000 milliseconds; effective TE, 90 to 130 milliseconds;
–FOV, 20 to 24 cm; section thickness, 4 to 5mm;
–intersection spacing, 1.0 to 2.0 ram, numberof signal averages
(NSA)2 to 4, ETL, 16;
–matrix of 512 • 256.
–The phase encoding direction : anterior to posterior,
– Using a20-cm FOV and a 512 x 256 matrix,
–in-plane resolution is 0.4 mm (frequency) by 0.8 mm(phase) .
•Axial and sagittal T1 weighted fat saturated sequences following the
administration of gadolinium diethylenetriamine penta-acetic acid (GdDTPA) contrast agent.
RESULTS
MRI findings
Case
description
Enhancement
Peritoneal signs
N°1
Loculated cystic mass with thin septations
and intracystic papillary projections
Not enhanced
small amount of
asites-
N°2
Multi loculated cystic mass with solid
component,thick septations, intracystic and
exophytic papillary projections
Enhanced solid
component, papillary
projections septations
and wall
Moderate ascites and
peritoneal implant
N°3
Multiloculated cystic mass with solid
component, thin septations without
papillary projections
Enhanced solid
component and wall
Peritoneal implants
N°4
Multiloculated cystic mass with solid
component, thin septations and intracystic
papillary projections
Enhanced solid
component, papillary
projections, septations
and wall
Small amount of
ascites
N°5
Multiloculated cystic mass with thin
septations without intracytic and exophytic
pseudocystic multiloculated papillary
projections
Enhanced septations
and wall
Moderate acites
Figure 1:
A 42-year-old female patient with a
mucinous ovarian BT.
Sagital and axial T2-weighted MRI image
(a, b), axial T1 without and following
intravenous contrast ( c, d) illustrates a
large cystic mass with one septa, a solid
component both not enhanced.
Normal right ovarian.
FIG 1a
FIG 1d
FIG 1b
FIG 1c
FIG 2a
FIG 2b
FIG 2c
Figure 2: A 31-year-old woman with a mucinous BT. Axial, sagital, T2-weighted, MRI image ( a, b).Axial T1 ©, Axial, sagital T1+C ( e, f), axial T1 +C
FS (d). A cystic lesion is present with numerous irregular septa and intra-cystic frond-like papillary projections involving both the wall and septa
enhanced following contrast. Exophytic papillary projections are also present extending from the posterior and inferior surface of the cyst (head
arrow) and are delineated by ascites. We notice cystic containing loculi with different signal intensity ( high T1 signal of hemorrhage)
FIG 2f
FIG 2e
FIG 2d
FIG 3a
FIG 3b
FIG 3c
Figure 3: A 51-year-old woman with a mucinous BT.
Sagital, coronal T2-weighted, MRI image ( a, b). Axial T1 ©,sagital, coronal and axial T1+C ( e, f,d).
Multiloculated cystic lesion is present with numerous thin septa enhanced following contrast.
FIG 3f
FIG 3e
FIG 3d
FIG 4a
FIG 4b
FIG 4c
Figure 4: A 42-year-old woman with a mucinous BT.
Sagital, coronal and axial T2-weighted, MRI image ( a, b ,c)
Multiloculated cystic lesion is present with thin septa and intracystic papillary projections.
MRI confirmed the ovarian site especially when considering voluminous
tumor. Signal intensity characteristics allowed better analysis of cystic and
solid components.
FIG 5
•Unialteral right ovarian mucinous
borderline epilthelioma
•Axial and sagittal T2-weighted ,
MRI demonstrates a cyctic lesion
with intracystic and exophytic
pseudocystic multiseptate papillary
projections; the exophytic part of
the tumor is extented from the
unterrumpted posterior surface of
the cyst and is delineated by
ascites.; notify the normal
appearing of the ipsilateral ovarian
stroma (arrow)
FIG 5 b
FIG 5 a
FIG 5 c
FIG 5 d
FIG 5 e
RESULTS
Treatment
Case
description
Histologica
l type
Peritoneal
implants
N°1
Hysterectomy. Bilateral annexectomy. Omentectomy.
Apendicectomy
Mucinous
BTs
No
N°2
Hysterectomy. Bilateral annexectomy. Omentectomy.
Apendicectomy
Mucinous
BTs
Not
invasive
N°3
Hysterectomy. Bilateral annexectomy. Omentectomy.
Apendicectomy
Mucinous
BTs
Not
invasive
N°4
Hysterectomy. Bilateral annexectomy. Omentectomy.
Apendicectomy
Mucinous
BTs
No
N°5
Right annexectomy. Apendicectomy
Mucinous
BTs
No
DISCUSSION
Definition:
Borderline ovarian tumours (BTs) are an intermediate category of epithelial
ovarian tumour, which histologically demonstrate cellular proliferation and
moderate nuclear atypia but without stromal invasion. Described by Taylor in
1929 (4), and recognized by the International Federation of Gynaecology and
Obstetrics and World Health Organization in the early 1970s (5), they occur in
all types of epithelial ovarian tumours but are most common in serous and
mucinous subtypes.
DISCUSSION
Classification:
I
Only Ovaries
a One ovary. Ascites (-). Papillary projection (-). No capsular rupture
b Bilaterality. Ascites (-). Papillary projection (-). No capsular rupture
c Unilaterality or bilaterality. Ascites (+) or positive cytology. Papillary
projection or capsular rupture.
II
Pelvic extension
a Uterus without positive ascites
b Bladder or rectum without positive ascites
c IIa or IIb with ascites or positive cytology or papillary projection or capsular
rupture
III Abdominal and pelvic peritoneal extension or lymph node metastases
a Peritoneal or omental microscopic extension Nb Peritoneal implants < 2 cm, Nc Peritoneal implants > 2 cm and/or pelvic, para aortic or inguinal N+
IV Pleural effusion / Parenchymal metastases
DISCUSSION
Histology (1,3,6,7)
Numerous subtypes are described; serous, mucinous, endometrioid, clear cells,
transitional cells and mixed tumours.
Serous BT’s:
Cystic mass with intracystic papillary projections or both intracystic and
exophytic papillary projection, exclusie exophytic papillary projections are
rare.
Mucinous BT’:
Intestinal: Voluminous multilocular cystic mass without papillary projections.
Extension: peritoneal pseudomyxoma. Bilaterality++ mucocele++
Mullerian: Unilocular or cystic mass with intracystic papillary projections.
Extension: bilaterality. Peritoneal implants
DISCUSSION
Clinical features:
Younger age at presentation.
Normal or midely elevated CA125
Prognosis:
Surgical factors, response to therapy and histological criteria are important for
predicting the prognosis of patients with BTs. Newer techniques such as
morphometry, DNA cytometry, immunological and immunopathological
techniques may help to define prognostic factors even more accurately (8).
DISCUSSION
Ultrasonography features:
Ultrasonography morphologic analysis of adnexal masses is accurate for
identifying ovarian site, suspecting epithelial tumor and to confirm its
neoplastic nature. However its specifity remains limited.
DISCUSSION
MRI features:
MRI signal and morphologic characteristics:
-Some authors interpreted high signal on T1 weighted images as diagnostic of the
presence of mucinous material suggesting an underlying diagnosis of a mucinous
BT (9) which is in contradiction with more recent studies in which high signal on
T1 weighted images is indicative of haemorrhage or mucinous material without
correlation with histological subtype of BT (10).
-In our study, we described a haemorrhagic component in a mucinous BT.
- For some authors, the presence of multilocular cystic mass containing loculi of
different signal intensities, numerous irregular septas are suggestive of mucinous
BT which is in agreement with our findings.
DISCUSSION
Size of lesion:
Mean maximal diameter and volume of lesion demonstrated the greatest
difference between the serous and mucinous subtypes (10).
Mean maximal diameter of our mucinous tumours series is 16,2 cm.
Ipsilateral adnexal findings:
In Literature, presence of normal ipsilateral ovarian stroma was identified in MRI
(10). In our study we noticed this finding in the smallest tumor of our series.
DISCUSSION
Controlateral adnexal findings:
Published literature noticed an important negative findings in which synchronous
bilateral BTs occurred only in the serous subset (11) which is in agreement with
our series consisting in mucinous borderline tumours since imaging demonstrated
unilateral disease in both US and MRI.
Ascites
Literature did not found correlation between pathological volume of free fluid
and histological subtype (12). But the relationship between the presence of a
pathological volume of free fluid and exophytic projections was established and
supports the increased risk of peritoneal disease (10).
In our study 2 patients demonstrated exophytic papillary projections which was
associated both to ascites and non invasive peritoneal implants in one case.
DISCUSSION
Some authors categorized MRI appearance of BT’s into 4 broad morphologic
groups (10) :
-Unilocular cysts
- Minimally septate cysts with papillary projections
- Markedly septate lesions with plaque-like excrescence
- Predominant solid lesion with exophytic papillary projections
In our present series MRI appearances can be categorized as one case in the
second category, one case in the third category and 3 cases in the fourth category.
DISCUSSION
Malignant criteria
- Bilaterality
- Tumour size greater than 4 cm
- Predominantly solid mass
- Cystic tumours with vegetations
- Contrast enhancement
Criteria suggesting borderline ovarian tumours
- At least one imaging feature to suggest malignancy
- Predominantly cystic appearing lesion
- Regular thin wall
- Presence of normal ipsilateral ovarian stroma
- Lack of ascites
- Lack of enlarged lymph nodes
- Lack of peritoneal and omental disease.
DISCUSSION
Criteria suggesting borderline ovarian tumours
- At least one imaging feature to suggest malignancy
- Predominantly cystic appearing lesion
- Regular thin wall
- Presence of normal ipsilateral ovarian stroma
- Lack of ascites
- Lack of enlarged lymph nodes
- Lack of peritoneal and omental disease.
DISCUSSION
Treatment
Fertility sparing surgery for patient with borderline ovarian tumor is safe and can
permit future pregnancy suggesting that such surgery should be considered for
young patients who wish to preserve fertility (13).
Radical surgery including bilateral annexectomy, omentectomy hysterectomy,
peritoneal cytology with numerous biopsies remind the typical procedure . (14,
15)
CONCLUSION
In young women with normal or moderately raised CA125 levels and a complex
adnexal mass, the possibility of borderline ovarian tumor should be considered.
MRI showed a wide array of BT’s appearances. Each lesion was associated at
least to one criteria of malignancy. Accurate preoperative characterization present
a special diagnosis challenge since it influences surgical planning and even
allows the possibility of fertility preservation.
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